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Speaking on the confusion, Coroner Hassell said: "I am not saying it would have changed the outcome, but in terms of best practice if you had said, 'He has told me he is looking for his asthma pump', then there may have been a different conversation with members of staff on the phone to the paramedics, and not focused on the EpiPen.

"There would have been an opportunity for the paramedic to know that the boy was looking for his asthma pump."

Hyde admitted that, with hindsight she may have asked for the teen’s inhaler, but added: “Everything he needed was in that pack.”

Distraught Ashrafuz and Ferdousi Zaman ... teen's parents heard their son had eaten tandoori lunch just two hours before collapse last year

Nasar, who was a Year Nine student, had asthma and severe eczema, in addition to a number of other allergies including milk, fish, nuts, wheat, some meats, apples and oranges.

Distraught parents Ashrafuz and Ferdousi Zaman, who were at the inquest, heard their son had eaten a tandoori chicken lunch that day at around 12.20pm, just two hours before he collapsed.

But pathologist Dr Liina Palm told the hearing it was not possible to determine whether their son had died from an asthma attack or an allergic reaction, going on the post-mortem alone.

Dr Palm said she found blood cells in his body during the examination which are commonly associated with an allergic reaction, however gave the cause of death as bronchial asthma that led to a hypoxic ischaemic brain injury, with multiple allergies as a contributing factor.

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